Reality of nurses in the care person with head and neck oncological wound : exploratory study

1Universidade Federal de Santa Catarina –Departamento de Enfermagem – Florianópolis/SC – Brasil. 2Centro de Pesquisas Oncológicas – Florianópolis/SC – Brasil. Autor correspondente: Lucia Nazareth Amante | Rua Desembargador Pedro Silva, 3162 – Apart. 210 – Coqueiros | CEP: 88080701 – Florianópolis/SC – Brasil | E-mail: luciamante@gmail.com Recebido: Mar. 09, 2018 | Aceito: Set. 11, 2018 RESUMO Objetivo: Conhecer a realidade dos enfermeiros no cuidado de enfermagem à pessoa com ferida oncológica de cabeça e pescoço. Métodos: Estudo exploratório descritivo com abordagem qualitativa. A entrevista semiestruturada ocorreu em julho de 2017 com 12 enfermeiros de um centro de referência oncológica do sul do Brasil. Os dados foram submetidos à análise temática proposta por Minayo. Resultados: Os enfermeiros realizam um cuidado integral com olhar ampliado baseado nos conhecimentos científi cos para escolher uma adequada terapêutica no tratamento da ferida. A educação permanente e a existência da equipe especializada facilitam a prática. Já as difi culdades, quando aparecem, envolvem a escolha terapêutica, a continuidade do tratamento domiciliar e o controle dos sintomas da ferida oncológica. Os enfermeiros reconhecem seu trabalho como essencial, gratifi cante e satisfatório por trazer melhora da qualidade de vida às pessoas. Conclusão: O objetivo do estudo foi alcançado, destacando-se o papel essencial do enfermeiro e os benefícios da educação permanente. Reafi rma-se que uma equipe especializada e uma enfermeira estomaterapeuta são fundamentais para a qualidade e resolutividade do cuidado de enfermagem para as feridas oncológicas.


INTRODUCTION
Head and neck cancer consists of the process of mutation or abnormal activation of genes that control cell growth and division, causing them to occur disorderly in the region 1 , especially a ecting the face, oral cavity, pharynx, larynx, the nasal cavity, the paranasal sinuses, the thyroid, salivary glands and soft tissues of the neck 2,3 .
Of these regions of the body the most incidental are oral cavity, esophagus and larynx 4 .
e Brazilian Society of Cancerology (BSC) reports that 70% of patients diagnosed with this type of cancer are already in an advanced stage, and when diagnosed at an early stage, the possibility of cure reaches 80% 3 .In this way, the early detection of this type of cancer is essential to prevent the complications caused by the exacerbated proliferation of the cells.Among these complications is the development of oncological wounds, which consists in the breakdown of skin integrity due to the infiltration of malignant tumor cells into the cutaneous structures due to the uncontrolled proliferation of the cells generated by the process of oncogenesis 5 .Other factors that contribute to its development may be related to the side e ects of cancer treatments, such as surgical and diagnostic procedures that may cause invasion of lymph nodes and implantation of tumor cells accidentally 6 .
Although there are few statistical studies about the incidence and prevalence of oncological wounds, it is known that the development of this type of wound can be found in 5 to 10% of people with some type of cancer, mainly in the head and neck, breast and skin [7][8] . is occurs because cancers involving the head and neck regions contribute most to the appearance of wounds in the presence of advanced disease, a situation directly related to late diagnosis and, most of the time, because of aggressive cancer and metastatic 6 .
The exteriorization of the tumor mass in the form of a wound, especially in the head and neck region, has an impact on people's lives due to their exposure and relation to esthetic, affecting socioeconomic, biological

DESCRIPTORES:
Enfermería; Oncología; Estomaterapia; Cuidados de enfermería; Neoplasias de cabeza y cuello; Heridas y lesiones.. and psychological factors through changes in body image, self-esteem, lifestyle and social relationships 9 .us, the person with a head and neck oncological wound needs multidisciplinary care, according to their biopsychosocial needs, and nursing care is essential in this process, especially during the healing 6,7,10 .
The nurse, therefore, needs to act based on up-todate knowledge according to the technological advances of the products available in the market, considering the characteristics of the wound and the clinical history.So, it can choose the appropriate therapy and, consequently, o er better quality in the care and improvement of the quality of life of these patients 6,7,10 .
In view of the variety of technologies for the topical treatment of wounds and the di cult management of head and neck oncological wounds, the necessity for professionals to act with knowledge about the available materials to be used according to the clinical characteristics of the wound, considering the quality of life of the patient and the signs and symptoms of the underlying disease, as these will in uence the therapeutic adherence chosen and the survival of these people 6,7,9,10 .
Despite all the advances in the technologies for the care of the person with wounds, it is noticed that there is still a shortage of research, lack of training and de ciency of the nurses' training process 6,7,11 .Likewise, the lack of knowledge about the characteristics to be identi ed in the assessment of wounds is high.is evaluation process can contribute to the early treatment of wounds, favoring the scar process and preventing the wound from developing and su ering a delayed scar process, causing a possible infectious process 12 .
Based on the recognition of the existence of the di culties experienced in the practice during the academic formation,

OBJECTIVE
To know the reality of nurses in the nursing care person with an oncological head and neck wound in an oncology reference center.

METHODS
is is an exploratory and descriptive research with a qualitative approach.The Center for Oncological The analysis of the data was performed through the thematic analysis proposed by Minayo composed of three stages: pre-analysis, analysis and interpretation of the data.us, after transcribing the information in its entirety, the material was read, and the information explored, selecting the sense nucleus and the synthesis words from which the study categories emerged.
Vicente C, Amante LN, Santos MJ, Girondi JBR, Rosa LM The research consists in one of the stages of the project " e accomplishment of the healing in the care of the person with head and neck oncological wound: an approach to the permanent education of nurses", approved

Evaluation of the person with head and neck oncological wound as the focus of nursing care
In this category, it is noticed that the nurse, in its care practice, must follow some principles to base its therapeutic choices during the accomplishment of the healing for person with head and neck oncological wound.erefore, scienti c knowledge and clinical reasoning should be used to observe and evaluate the characteristics of the wound to choose the appropriate therapeutic product, considering the availability of materials o ered by the service institution.
I will choose as the injury presents itself and depending on the products we have.Based on my knowledge and the courses we have already taken.(E3) For better evaluation, the professional must consider the etiology of the wound, the history of the patient, its clinical conditions and the type of therapy.ese aspects will allow the continuity of cancer treatment, as its directly in uence this care.Other related aspects that deserve to be highlighted are the environment where the patient is inserted and the continuity of the treatment at home, considering the availability of the products for this care, the reference to the basic health unit and the guidelines for the patient and family.
First, we know the patient a lot, the conditions that the patient will have to continue the treatment at home.I see who can take care of this healing.Because depending on where the wound is, it needs the help of someone else.If it needs, we'll contact the health post to see if it can continue this healing.We also take care of the environment that will be realized the healing, we do not always have their own places, but if it is a large healing that is contaminated, it smells great, I try to be using a speci c place.(E7) Regarding the di culties in the healing management, most nurses report having no di culties, however, they need the support and assistance of a specialized team.
Usually not here.If it has, we ask for the support of M., who is a stomatherapist.So, we end up resorting to it when it does.(E2).
When the di culty arises, it is generally associated with the therapeutic selection for some speci c characteristic presented by the oncological wound or when modifying the therapeutic conduct that was being used.
Sometimes in choosing the product.Often, we turn to another professional who deals with wounds to get some doubt.(E10) Reality of nurses in the care person with head and neck oncological wound: exploratory study Di culty in noting when to change the product.Because we think we must keep the coverage improving, and one of the things we see is that sometimes it's time to change the product of the injury.(E6) Another difficulty refers to the offer of products and the nancial conditions of the patient to buy the materials and give continuity to the care at home, since the treatment is for a long period.In addition, there is a constant lack of quality materials in primary health care.
One di culty is that we cannot provide the material and We feel very comfortable here as a nurse, in evaluation and in the conduct of conducts.Even with the medical team, when we have any doubts, we end up asking them for some opinion.Because we work as a team, when we have doubts, we ask a colleague who is more time, we do it together.(E11) erefore, it is perceived that professionals recognize the importance of integral care to perform wound evaluation with quality, as well as important factors related to working and institutional conditions that facilitate their work process.Already the di culties, although they exist, are little highlighted, due to the support of a support team and the process of permanent education in force in the institution.

Nurses' perception of care of the person with a head and neck oncological wound
is category aims to show the nurses' vision on the performance of their work, focusing on their feelings, their perception and their point of view.It should be emphasized that the nurse has a great responsibility in the care of the person with a head and neck oncological wound, since it must perform an integral care, considering the biopsychosocial issues and the orientations in the home care to the patient and their relatives, providing quality of life and well-being.
As an oncological nurse, I see beyond the wound, because a wound does not heal on its own, it need to try to encourage that healing because it is already having several factors that will make it di cult.So, I think we have a great responsibility, we are very important in this orientation process.We may not be able to close, but it will enable the patient to live with it.(E7) We do our best so that, even in the nal moments of life, they have a good quality of life.(E12) e role of nurses is crucial because they are dealing with skin care that directly interferes with the appearance of these people, causing various biopsychosocial factors to be mobilized in this process.

DISCUSSION
Care with oncological wounds is extremely di cult due to the degree of complexity of the clinical condition of this patient, and for this reason requires a dynamic, complex and specialized care process 13 .For this, the nurse must know how to perform nursing care for the person with head and neck oncological wound, especially those related to the wound, since, among the attributions established in Cofen Resolution nº 501/2015, this professional has autonomy in the prevention, implementation of treatment and rehabilitation in the care of people with wounds 14 .
e nurse has the responsibility to make the healing, acting in the prevention, evaluation and indication of the appropriate treatment of the wound, according to the characteristics.For this, it needs scienti c knowledge, to be aware of the topical therapies available to adapt them to the economic reality of the patient 7,14,15 .
The therapeutic choice should be made through scienti c knowledge and clinical reasoning of the nurse.
According to Santos et al. 12 , the nurse "must be equipped with the technical knowledge and competence to identify, evaluate and treat these oncological wounds, providing an individualized and integral assistance to the holder and its family."us, in this study, the pro le of a nurse, increasingly focused and committed to updating and performing the care using proven scienti c techniques, aiming at o ering a better service quality and recognition of the profession is observed.is process of transformation occurs due to changes in education and modern society that require more and more competent professionals and stand out through the autonomy to solve problems in the practice of care. is occurs when the professional stops using the isolated technical reasoning and associates it with the scienti c evidence, such as new trends and perspectives, combining technical-scienti c knowledge, humanization and individualization of care 13,16 .
In the assessment of the person with head and neck oncological wound, it is necessary to make a clinical judgment about the pathophysiological evolution of each person and to know the factors that in uence the therapeutic process after planning the nursing care, guiding the patients for self-care and family members or caregivers to provide care, as well as record the activities performed 17 .
In this study, professionals also present this di erentiated look by not focusing on the therapeutic choice only in the evaluation of wound characteristics, such as the types of tissues and exudates present.ey take into consideration the etiology, the history of the patient, the clinical conditions and the type of therapy used to treat cancer that may in uence the treatment of the wound.Thus, the importance of assessing the clinical conditions of the patient is perceived, since the intrinsic, extrinsic and local factors interfere directly in the treatment 8,15 .
Another aspect is related to the care with the environment where the healing will be performed in the institution, as well as its continuity at home.us, the patient's family, social and nancial conditions must be considered.e health conditions and lifestyle of the patient, which includes the home, work, family and nancial resources, directly a ect the activities performed 18 .
In this sense, the therapeutic choice will be in accordance In this sense, the organization, the structure of the service, the therapeutic choice and the availability of the products are di culties faced by the nurses 7,8,11 .It should be emphasized that the institution has several products for the treatment of the wound in the institution, but not enough for all patients to take home when there is no o er of the product in the primary health care. is situation is pointed out as a di culty for the continuity of care with the head and neck wound in the home and it is reported when they mention that the health units lack of material and medicated resources for the treatments 7 .
e odor and bleeding cited as di culty in performing the healing are important aspects, since they present characteristics that di erentiate oncological wounds from others and that can unleash self-image disturbances and social problems, mainly due to their location 19 .At no time, however, emotional issues were reported as di culty in caring for these patients.
According to the integrative review of Santos et al. 16  Although there is a contradiction when referring to autonomy, because they are conditioned to the opinion of the stomatherapist nurse practitioner in decision making, it is necessary to understand that having autonomy does not mean having total control of their professional actions, but recognizing their capabilities and limitations, being free to perform decisions and their own choices in the face of multidisciplinary work, using scienti c knowledge and taking responsibility for their conduct 21,22 .
Nurses have the perception about their service represented as a job with great responsibilities, which are mainly attributed to the provision of nursing care in diagnostic evaluation, treatment, rehabilitation and patient and family care.In this sense, the adequate therapeutic choice for the evolution of the wound and improvement of the quality of life of the patients makes this care extrapolate the limits of the disease 23 .
e nurse also plays a fundamental role in helping to control the psychological e ects in this patient.is point is essential for the treatment of the patient and shows a diversi ed and sensitive view of nurses considering the biopsychosocial aspects, especially the patients with head and neck oncological wound.
Vicente C, Amante LN, Santos MJ, Girondi JBR, Rosa LM To this end, this professional should perform a humane and unique care, o ering psychological support to patients, who, in addition to having to deal with a lifethreatening illness and the impacts of treatment, must face changes in the functional and esthetics.e change in self-image a ects social relationships and the execution of daily activities, but also brings with it the continuous view of its clinical picture, referring to the meaning of ine ective treatment, disease progression and even death 24 .
As a limitation, it is pointed out that this study was performed in a single health institution, although it is a reference for the treatment of cancer in the region of Santa Catarina, which exclusively serves the Uni ed Health System.
e recommendations are to extend this study to other institutions, to check the potentialities and weaknesses in relation to the care of the person with head and neck oncological wound, as well as to investigate the therapeutic itinerary and quality of life of this patient, in order to that the line of care that is being drawn today is analyzed and discussed.

CONCLUSION
The objective of the study was reached, and it is perceived that nurses have an essential role in this care, performing quality care through practice based on scienti c evidence.For this, the study shows the bene ts that the permanent education program brings to nurses' care, aiming at the best resolution of the problems experienced in practice.
It is rea rmed that the existence of a specialized team to care for the person with wounds, with the availability of a stomatherapist for evaluation and clari cation of the doubts of the team, is essential so that this care is resolutive and of quality.
Research (Cepon), a reference center for cancer treatment in the state of Santa Catarina, Brazil, and a reference of the World Health Organization (WHO) for palliative medicine in Brazil, was the study scenario.The study's target audience was the institution's nurses who met the inclusion and exclusion criteria.e inclusion criteria consisted of working directly with the care of the person with head and neck oncological wound, performing the clinical evaluation of the oncological wound and the therapeutic choice of the healing.e exclusion criteria were to work for less than 6 months in the institution and be on leave, attestation and/or vacations at the time of data collection.A study sample of 12 nurses was obtained.Data collection was performed through an interview with a semi-structured questionnaire, organized in two parts: the rst one for the professional pro le of the participants and the second one related to the nurses' work process, seeking the reality that these professionals experience in the care of people with cancer of the head and neck.e interviews were realized in July 2017, lasting approximately 15 to 30 minutes, individually, at a place and time previously agreed with the participants.e audio recording of the interviews was later transcribed, and the letter E followed by the whole and sequential number (E1, E2, E3, etc.) was used to identify the participants.
RESULTSe participants' age ranged from 29 to 46 years, with graduation time of 5 to 22 years and service period of 1 to 14 years, women predominance and postgraduate training, with the majority with specialization and one with master's degree completed.Of these nurses, four works in the outpatient clinic and eight in the hospitalization units.Data analysis allowed the formation of two categories: evaluation of the person with head and neck oncological wound as the focus of nursing care and the perception of the nurse in the care of the person with head and neck oncological wound.
the patient cannot a ord it.And oncological healings are used for months.And the health post does not have this kind of material to provide and give continuity.(E8) e di culties with odor and bleeding care, which are the main features of the head and neck oncological wound, are also highlighted and may be vital for the treatment of this type of wound, generating serious complications that may aggravate the clinical picture.Sometimes the oncological wound, especially the head and neck, has a lot of odor and bleeding, so my fear is to bleed, it has all that part of solving the bleeding issue, and I'm very scared of it.(E9) Among the facilities indicated by the nurses are the varied availability of products in the institution, groups of curative studies and the support obtained by the nursing team to assist in the evaluation and therapeutic choice of wounds.ey also highlighted the freedom to work to realize the practices and the ability to work as a team, obtain the support of other health professionals and realize a multidisciplinary care.Of facilities we have our stomatherapist nurse that gives a support for us.Facility of having a lot of material for healing and frequent training in relation to injuries.(E3) with the economic conditions of the patient or with the availability of the products o ered in the institution, guiding the patient and the family to perform these care or to perform them in the basic units.It is evidenced that the participants of this study have a humanized and concerned look at the continuity of care for patient recovery.It seeks the integrality and the improvement of the quality of life, essential during Reality of nurses in the care person with head and neck oncological wound: exploratory study the accomplishment of the nursing care to the people with oncological wounds17 .On the other hand, the main di culties are lack of experience and speci c training, lack of knowledge and technical competence, and lack of interdisciplinary discussion and permanent education in the institution for action in the area6,7 .In this research, however, participants stated that they did not have difficulties to perform the healing because they received support from the stomatherapist nurse and the work team, as well as the fact that the institution o ered courses and training in its permanent education program.When questioned, however, they report that, when discussing with the team about the decisions, these are, in most cases, focused on the choice of therapy to be used, on the identi cation of the moment of therapeutic change, on the availability of the product for continuity of home care and the management of odor and bleeding, showing di culty in therapeutic management, although they have been cited as non-existent.It is noticed, therefore, that the professionals do not recognize their di culties in the work process, because they sustain on the existence of a support team.Despite being a strong point of the institution, this fact can be generated by the professional's insecurity in taking its own conduct alone, because, despite having knowledge about the subject, the connection with the specialized team is always maintained, overloading it, an instead it should act only in speci c cases.
, the generalist graduation curriculum is insu cient for oncological care, due to the limited knowledge o ered in the training, most of whom only have contact with the subject in their work environment, which causes di culties in the provision of services.Regarding nursing care for people with oncological wounds, it is no di erent: the professionals' di culties are also related, mainly, to the lack of researches worldwide, the lack of training and the de ciency of the training process, which causes di culties in the management of care practice due to the lack of standardization for the healing, making the professionals employ knowledge of wounds in general when dealing with a person with oncological wound6,7,11 .efacilities are mainly related to the routine of the institution, and can be veri ed, through the reports, the availability of products in the institution, the possibility of daily clinical evaluation of the wound, by the o er of updates and training by the institution itself, freedom to take and again, the support of the team.Autonomy consists of decision making through conscious clinical reasoning and can be stimulated through an environment with freedom in the conduct of work, since it enables autonomy development and nurses' empowerment20,21 .
by the Human Research Ethics Committee of the Federal evaluate the skin, I see what chemotherapy and radiotherapy is doing, whether it is doing it or not.